Basic Information
| Provider Information | |||||||||
| NPI: | 1710986500 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILLHAM | ||||||||
| FirstName: | FREDERICK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 MAIN ST | ||||||||
| Address2: | STE. 670 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087543566 | ||||||||
| FaxNumber: | 5087988012 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 WASHINGTON ST | ||||||||
| Address2: | SUITE 670 GREEN | ||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024621650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172486496 | ||||||||
| FaxNumber: | 6172436669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 09/10/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 72445 | MA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3079171 | 05 | MA | MEDICAID |